SHAN STATE A Snapshot of Child Wellbeing BASIC INFORMATION

Area: 155,457.45 sq. km

Total population: 4,493,308 Rural: 3,447,611 Urban: 1,045,697 0-14 years: 1,431,049

Languages: Myanmar, Other

Administrative divisions: 13 Districts, 55 Townships, 491 Wards, 15,902 Villages

Capital: Taunggyi

Main economic activities: Mining, Forestry, Agriculture

SOCIO-ECONOMIC CONTEXT Located in eastern Myanmar, Shan State is bordered by China to the north, China and Laos to the east, Thailand and Kayah and Kayin States to the south, and Mandalay and Sagaing Regions to the west. Occupying about a quarter of Myanmar’s total land area, it is the largest of all states and regions in the country. Shan State is endowed with vast reserves of timber, coal, metals and precious stones. It is famous for its garden produce as the temperate climate lends itself to growing a variety of fruits and vegetables. And it is also home to Inle Lake, one of the biggest tourist attractions in Myanmar. However, years of civil and political strife, coupled with large scale illegal production of opium and heroin, have adversely affected socio-economic development in the State despite the tremendous potential. Now home to 5 of the 6 self-administered areas in the country, and with continued conflict between the Government and ethnic armies on some fronts, vast areas in the State remain un- reached by essential public services and household-based data collection exercises alike. It is therefore highly plausible that the socio-economic situation may actually be worse than indicated by available data.

CHILD WELLBEING Children have basic needs, such as adequate nutrition Underweight and healthcare, that if unmet could result in long-term 24 Shan North consequences, including limitations on their physical and cognitive development and consequently wellbeing in Not immunized (DTP3) 11 adulthood. Their experience of poverty is multidimension- Shan North al and deprivation in any of the key dimensions (i.e. nutri- Not using improved water tion, health, education, care and protection, water, sanita- 19 source tion and income) compromises their wellbeing. Shan North Not using improved As depicted in the chart, a sizeable proportion of children 32 sanitation in Shan continue to have some of their most basic needs Shan North unmet, with a much greater extent of deprivation in Shan Not completing primary North and Shan East compared to Shan South across a 64 school on time number of indicators. For example, only 48 per cent of Shan North births are registered in Shan North and 46 per cent of the population is living below the poverty line in Shan East. Birth not registered 48 Shan North How children in Shan fare (compared to the average My- anmar child) in each of the key dimensions of wellbeing is Living below poverty line 46 examined more closely on the following pages. A table on Shan East the last page presents data on a slightly wider range of 0 10 20 30 40 50 60 70% child wellbeing indicators. Sources: MICS 2009-2010; IHLCA 2009-2010

1 NUTRITION Underweight Stunting Wasting Good nutrition is a cornerstone for survival, health and development. Well- nourished children perform better in school, grow into healthy adults and in turn Shan 18 give their children a better start in life. 42 South 5 Given the optimum start in life, all children have the potential to develop within the same range of height and weight. This means that differences in children's Shan 16 39 growth to age five are more dependent on nutrition, feeding practices, environ- East 3 ment and health care than on genetics or ethnicity. Shan 24 The chart shows how children in Shan South, Shan East and Shan North fare on 47 North the three standard measures of malnutrition (underweight, stunting and wast- 9 ing). The prevalence of stunting (or low height-for-age) is alarmingly high with as National 23 many as 47 per cent of children being stunted in Shan North. Stunting is a con- 35 Average sequence of chronic malnutrition and can have irreversible damage on brain 8 % development. If not addressed in the first two years of life, stunting diminishes 0 20 40 60 80 the ability of children to learn and earn throughout their lives. Source: MICS 2009-2010

Births in Immunization ORT HEALTH health facility (DTP3) Use Rate Significant reductions in maternal and child mortality can be achieved through a few simple health interventions, including giving birth in a health Shan 23 100 facility (or at least in the presence of a skilled birth attendant), timely im- South 87 munization against some of the main childhood illnesses, and adequate Shan 41 management of diarrhoea including oral rehydration therapy (ORT) etc. 98 East A low proportion of children born in Shan State are likely to be born in a health facility where life-saving obstetric care would be available for mother 26 Shan 89 and child in case of complications during birth. According to available data, North 28 the proportion of births in a health facility range from 23 per cent in Shan South to 41 per cent in Shan East. Immunization rates appear comparable National 36 98 to the national average in Shan South and East but are almost 10 percent- Average 66 age points lower in Shan North. The use of oral rehydration therapy (ORT), to prevent life-threatening dehydration associated with diarrhoea among % 0 20 40 60 80 100 children, is employed in 87 per cent of the cases in Shan South and only Source: MICS 2009-2010 28 per cent of the cases in Shan North.

HIV HIV-testing for ART for HIV-testing Elimination of mother-to-child transmission of HIV is a key component of the pregnant women PMTCT for infants global response to HIV for young children. Steady expansion of HIV testing, par- Shan 58 ticularly of pregnant women, and provision of the most effective antiretroviral 36 treatment (ART) offers hope that mother-to-child transmission can be virtually South 42 eliminated in low- and middle-income countries as well. Shan 55 40 The Myanmar National Strategic Plan on AIDS 2011-2015 includes prevention East of mother-to-child transmission (PMTCT) as a priority and various related indica- Shan 51 tors are regularly monitored. Among those reached by the public health system, 84 North fewer than 60 per cent of pregnant women across Shan are likely to be tested 21 for HIV and receive the test result. Whether pregnant women identified as HIV- National 51 82 positive in the State receive ART for PMTCT varies considerably between Shan Average North and South. And to a lesser extent, so does the probability of an infant 10 born to an HIV-positive woman being tested for HIV within the prescribed 2 0 20 40 60 80 100 % months after birth, which is as low as 21 per cent in Shan North. Source: National AIDS Programme, 2012

Access to improved water sources among households WATER Diarrhoea prevalence among children According to the Multiple Indicator Cluster Survey (MICS), the proportion of households not using improved water sources in Shan ranges from 1 per Shan 89 cent in Shan East to 11 per cent and 19 per cent respectively in Shan South 6 South and Shan North. However, the Knowledge Attitudes and Practices (KAP) Survey on Water and Sanitation conducted in 2011 in 24 townships Shan 99 nationwide, including 4 from Shan State, suggests that the situation might East 3 be much worse in some areas. According to this survey, as many as 35 per cent of households in Kutkai township (Shan North) are not using improved Shan 81 water sources and 37 per cent in Pinlaung township (Shan South) are not. North 6 Lack of access to safe drinking water is a major contributor to diarrhoea National 82 prevalence, with 80% of child deaths due to diarrheal disease being at- Average 7 tributed to poor drinking water, lack of sanitation and poor hygiene. Similar to the trend observed in Myanmar as a whole, diarrhoea prevalence among 0 20 40 60 80 100 % children aged 0-59 months in Shan has increased slightly since 2003 Source: MICS 2009-2010 (when it was 2% in Shan North, 3% in Shan East and 5% in Shan South).

2 SANITATION Access to improved sanitation According to the Multiple Indicator Cluster Survey (MICS), the propor- Open defecation tion of households that do not have access to improved sanitation in Shan State ranges from 8 per cent in Shan East to 32 per cent in Shan Shan 86 North. And open defecation rates are higher in Shan East and Shan South 0.2 North (3 per cent each) compared to Shan South (0.2 per cent). Shan 92 The 2011 KAP Survey on Water and Sanitation revealed that the situa- East 3 tion may actually be much worse, especially in some areas. For exam- ple, about 52 per cent of households were not using improved latrines Shan 68 in Kutkai township (Shan North). North 3

Improved sanitation can reduce diarrheal disease by more than a third, National 85 and can significantly lessen the adverse health impacts of other disor- Average 7 ders responsible for death and disease among millions of children. Investment in hygiene promotion, sanitation and water services is also 0 20 40 60 80 100 % among the most cost-effective ways of reducing child mortality. Source: MICS 2009-2010

Pre-school attendance EDUCATION Primary school enrolment Myanmar generally lags behind other countries in the region on education Primary school completion indicators due to decades of underinvestment in the education sector. Shan 35 92 Pre-school attendance among children aged 3-5 years is quite low with South 59 less than a quarter of all children attending nationwide. Shan North and Shan East have similar pre-school attendance rates (22 per cent) but Shan 22 75 Shan South appears to have a slightly better situation with over one third East 51 of children attending pre-school. Intellectual and social stimulation in ear- Shan 22 ly childhood, as provided in pre-school, is important for a child developing 85 North 36 to his or her full potential. And children who attend pre-school tend to do much better in primary school. National 23 88 The primary school enrollment rate in Shan ranges from 75 per cent in Average 54 Shan East to 92 per cent in Shan South. Fewer than 60 per cent of chil- 0 20 40 60 80 100 % dren complete primary school on time across the State, with as few as 36 Sources: MICS 2009-2010; IHLCA 2009-2010 per cent doing so in Shan North.

CARE AND PROTECTION Births registered Children not living Quality data on the most salient child protection issues in Myanmar, w/ a biological parent such as children living in out-of-home residential care, children living Shan 79 and working on the street and children in hazardous forms of work, is South 3 currently unavailable. It is expected that with the population census and Demographic Health Survey in 2014-2015, relevant data will be Shan 95 collected and analyzed. East 6 Currently available indicators include proportion of births registered Shan 52 and proportion of children not living with a biological parent. Only North 3 about half (52 per cent) of all births are registered in Shan North. Unregistered children are not only deprived of their basic right to a National 72 legal identity but are also more vulnerable to exploitation. With re- Average 5 gard to the proportion of children not living with a biological parent, % the situation in Shan (3-6 per cent) is more or less comparable to the 0 20 40 60 80 100 national average (5 per cent). Source: MICS 2009-2010 INCOME Poverty incidence While income alone is not sufficient to ensure a child’s wellbeing, it often enables families to have better access to quality education, health care, Shan 25 water and sanitation. South

Income poverty data are not as yet available in Myanmar. Shan 46 However, the Integrated Household Living Conditions Assessment (IHLCA) East allowed estimation of monetary poverty, as measured by consumption expenditure on food and non-food items. Shan 37 North According to this measure, about 25 per cent of the population was esti- mated to be living below the poverty line in Shan South which is compara- National ble to the national average (26 per cent). Higher levels of poverty were 26 Average % estimated for Shan North and Shan East; 37 per cent and 46 per cent respectively, with the latter being second only to Chin State where 73 per 0 20 40 60 80 cent of the population was estimated to be living below the poverty line. Source: IHLCA 2009-2010 3 TABLE OF INDICATORS FOR SHAN STATE

Shan Shan Shan National Highest Lowest INDICATOR North East South Average Incidence Incidence

Underweight: % of children aged 0-59 months who measured below -2 SD 37. 4 13.0 24.1 15.5 17.7 22.6 international reference weight for age Rakhine Kachin Stunti ng: % of children aged 0-59 months who measured below -2 SD 58.0 24 46.9 38.5 41.8 35.1 international reference height for age Chin Yangon Wasti ng: % of children aged 0-59 months who measured below -2 SD 10.8 2.3 9.4 3.4 5.3 7.9 international reference weight for height Rakhine Kayah Exclusively breastfed : % of children aged 0-5 months who are 47 1.3 NUTRITION 12.9 23.3 27.8 23.6 exclusively breastfed Mon Rakhine Vitamin A supplementation : % of children 5-59 months who never 13.1 6.4 26.1 12.9 10.3 10.6 received vitamin A Chin Bago West Ante-natal care visits: % of pregnant women receiving ANC one or more 99.6 75.6 63.2 98.6 98.7 93.1 times during pregnancy Mon Chin Ante-natal care quality : % of pregnant women who had urine specimen 91.2 16.2 32.5 77.9 73.2 56.9 taken Mon Chin Births in health facility : % of ever married women aged 15-49 who 68.9 5.6 26.2 41.1 23 36.2 delivered in health facility Yangon Chin Immunization: % of children aged 12-23 months who received DPT3 100.0 91.0 89 98.3 100 97.8

MATERNAL &

CHILD HEALTH vaccinations Mon Chin ORT Use Rate : % of children aged 0-59 months who had diarrhoea in the 90.2 47.2 [27.7] [*] [86.7] 66.3 last two weeks and received ORT Thanintharyi Kachin HIV-testing for pregnant women : % of women attending ANC who 98.2 12.1 50.7 54.9 57.8 51 tested for HIV and received the result Kayah Chin ART for PMTCT: % of HIV-positive pregnant women who received 102.2 35.7 antiretroviral drugs to reduce the risk of mother-to-child transmission 83.8 40.3 35.7 82 HIV Magway Shan South during pregnancy, delivery and breastfeeding HIV-testing for infants: % of infants born to HIV-positive women 42.4 1.1 21 42.4 9.5 receiving a virological test for HIV within 2 months of birth Shan South Magway 92.5 51.1 Improved water : % of households using improved water sources 81.4 99 89 82.3 Yangon Kayin Diarrhoea prevalence : % of children who had diarrhoea in the last two 13.1 2.5 6.1 2.8 5.9 6.7 weeks Chin Sagaing Improved sanitation: % of households with access to sanitary means of 93.8 48.0 68.3 92.1 85.6 84.6

WATER & excreta disposal Yangon Rakhine

SANITATION 40.7 0.3 Open defecation: % of households practicing open defecation 3.1 2.9 0.2 7 Rakhine Yangon Early childhood education : % of children aged 36-59 months currently 60.7 5.4 22.1 22.4 35 22.9 attending early childhood education Kayah Rakhine 96.3 71.4 Primary school enrolment: Net Enrolment Rate in Primary School 84.6 75.1 91.5 87.7 Kayah Rakhine 72.3 31.7 EDUCATION Primary school completion : Net Primary School Completion Rate 36.1 51.1 59.3 54.2 Thanintharyi Rakhine Birth registration: % of children aged 0-59 months whose births are 95.2 24.4 52.3 95.4 79.2 72.4 registered Yangon Chin

Parental care : % children aged 0-17 years in households not living with a 18.7 1.3 CHILD 3.4 6.1 2.7 5.4 biological parent Mon Rakhine

PROTECTION

73.3 11.4 Poverty incidence : % of population who are poor 37.4 46.4 25.2 25.6 Chin Kayah

INCOME

Figures in parenthesis indicate that the percentage or proportion is based on 25-29 unweighted cases only. An asterisk indicates fewer than 25 unweighted cases. NOTES All data presented herein, except on the following indicators, comes from the Multiple Indicator Cluster Survey (MICS) 2009-2010.  Area and Population: Health Management Information System (HMIS) Township Profiles 2011  Administrative divisions: 2012 MIMU P-Codes Release V (based on the 25 February 2011 Gazette issued by the Ministry of Home Affairs — with UN/NGO field office updates on the number of villages)  Poverty Incidence and Primary School Net Enrolment Rate: Integrated Household Living Conditions Assessment (IHLCA) 2009-2010  HIV-testing for pregnant women, ART for PMTCT and HIV-testing for infants: Myanmar National AIDS Programme 2012 (This is pro- gramme data, and unlike the data on the other indicators, is likely not representative at the state/regional level.) The map was developed by the Myanmar Information Management Unit (MIMU) upon request by UNICEF. 4